Provider Demographics
NPI:1003481755
Name:MIND BODY RISE
Entity Type:Organization
Organization Name:MIND BODY RISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGG DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-912-9584
Mailing Address - Street 1:808 STONINGTON RD
Mailing Address - Street 2:
Mailing Address - City:STONINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06378-2530
Mailing Address - Country:US
Mailing Address - Phone:860-535-9922
Mailing Address - Fax:
Practice Address - Street 1:808 STONINGTON RD
Practice Address - Street 2:
Practice Address - City:STONINGTON
Practice Address - State:CT
Practice Address - Zip Code:06378-2530
Practice Address - Country:US
Practice Address - Phone:860-535-9922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty